Journal Article > Commentary

Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.

Audiovisual > Audiovisual Presentation

Hospitals and health systems face challenges in implementing electronic health records that can affect safety. This webinar introduced the SAFER guides, which highlight strategies to improve safety related to electronic health record use, and educate participants about ways to implement these guides in their organizations. The session featured Hardeep Singh and Dean F. Sittig as speakers.

Book/Report

This Web site provides access to a collection of practice reports on patient safety and quality improvement initiatives in the United Kingdom. The latest update includes articles on efforts to enhance the safety of medication reconciliation, warfarin administration, learning culture, information documentation, and handoffs.

Journal Article > Study

This qualitative analysis of medical students' perceptions revealed persistent concerns related to the safety of transitions in care, despite much attention and recommendations related to improving handoffs. The most common cause of frustration among students was poor communication, which included unclear discussion about responsibilities, incomplete explanation regarding patients' needs, and inadequate identification of health care workers involved with the handoff.

Journal Article > Study

Communication between hospital-based and outpatient physicians is often suboptimal, and is thought to play a role in precipitating adverse events after discharge and rehospitalizations. However, this case-control study found that performance of several aspects of discharge communication—including medication reconciliation, discharge summary completion and quality, and patient education—did not decrease the risk of readmission. Other studies of specific discharge interventions, such as arranging outpatient follow-up or pharmacist review of medications, have also not affected readmission rates, meaning that preventable readmissions may only be reduced through more comprehensive (and resource-intensive) programs.

Special or Theme Issue

This is the fifth in a series of special issues devoted to exploring Canadian patient safety organizational and strategic improvement efforts. The articles highlight work related to topics including critical occurrence review, hand hygiene compliance, and effective handoffs.

Perspectives on Safety > Interview

Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.

Journal Article > Review

Radiation oncology is one of the more technologically sophisticated fields in medicine, requiring close collaboration between physicians, technologists, and medical physicists. High-profile errors in this field have been attributed to rapidly changing technology and human factors, and this review sought to characterize the types and frequency of errors and near misses in routine radiotherapy practice using data from voluntary error databases as well as published literature. Although the overall incidence of errors appears low, most reported errors were considered preventable, as they occurred due to faulty information transfer. The authors discuss the types of errors that may occur at each stage of radiotherapy and recommend error prevention strategies.

Perspectives on Safety > Interview

Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program. His role as a practicing clinician at a safety net hospital (San Francisco General Hospital) has put him in a unique position to pursue influential and relevant research related to health literacy and improving care for vulnerable populations.

Book/Report

The quality of care delivered at US hospitals continues to improve, according to data gathered by the Joint Commission from nearly 1,500 institutions. Hospitals improved their provision of evidence-based care for patients with heart attacks, congestive heart failure, and pneumonia, and also improved at prevention of health care–associated infections in surgical patients. As in the 2007 report, adherence to the National Patient Safety Goals was more mixed. Although performance improved in some areas (including medication reconciliation and eliminating "do not use" abbreviations), many hospitals do not systematically perform time outs prior to procedures, or have reliable mechanisms for communicating critical test results.

Cases & Commentaries

A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.

Journal Article > Study

Physicians reported dissatisfaction with their ability to follow up on test results in a timely fashion, with resident physicians frequently reporting an inability to check test results in less than 1 week. The need for standardized methods for following up test results in ambulatory care was noted in a prior study.

Journal Article > Study

The importance of standardized handoff communications in preventing errors is underscored by its inclusion as a National Patient Safety Goal, and specific guidelines have been developed to promote safe handoff practices. Despite this, multiple studies demonstrate that signout practices are still suboptimal, particularly at academic hospitals. Further corroborating evidence is supplied by this survey of medical and surgical residents at a teaching hospital. The majority of residents reported witnessing patient harm due to inadequate signouts, and signout practices often did not conform to recommended guidelines—specifically, signouts were often conducted over the phone or were subject to frequent interruptions. An AHRQ WebM&M commentary discusses a case of an inadequate signout that resulted in an adverse event.

Cases & Commentaries

An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.

Legislation/Regulation > Sentinel Event Alerts

Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission.

Journal Article > Study

With reductions in resident work hours, a greater number of communication failures have resulted, largely due to an increased number of "sign-outs" between providers. Despite the development of educational curricula, best practice guidelines, and computerized systems for sign-out, the patient care issues that remained around ineffective transfer of information elevated the issue into a National Patient Safety Goal. This prospective audiotape study analyzed more than 500 sign-outs and discovered omission of key information that potentially contributed to delays in diagnosis and treatment from covering providers, near misses, and several inefficiencies or redundancies in work. The authors also reported that failures to provide an accurate overall picture of the patient led to challenges with overnight decision-making. A past AHRQ WebM&M commentary discussed a sign-out–related error and the necessary systems to ensure safe and effective sign-outs.